Agoraphobia DSM-5 300.22 (F40.00)

DSM-5 Category: Anxiety Disorders

Agoraphobia

Agoraphobia is a DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis assigned to individuals who have a disproportionate fear of public places, often perceiving such environments as too open, crowded or dangerous. An anxiety disorder, agoraphobia can manifest in symptoms of distress and panic, disrupting sufferers’ everyday lives.

Introduction

Agoraphobia is an anxiety disorder characterized by a fear of certain environments and situations. Best known as a fear of open spaces, agoraphobia is, in fact, a much broader condition, and can apply to individuals who struggle with situations such as leaving the house, standing in line or using public transport.

Entering a public place - or anticipating such a scenario - causes someone with agoraphobia to experience disproportionate feelings of fear. This, in turn, manifests as distress, and sufferers often experience a panic attack or related symptoms, including breathing difficulties, a rapid heart rate and excessive sweating.

Agoraphobia may develop at any age, however, it typically presents between the ages of 20 and 30. Both women and men can be affected, although statistics show that the condition is more prevalent among women1).

SYMPTOMS OF AGORAPHOBIA:

Symptoms of agoraphobia include the following:

Lifestyle symptoms

Becoming isolated or detached

Feeling afraid of being alone

Overdependence on others

Being afraid of losing control in public

Avoiding places that may be difficult to escape from

Refusing to leave the house

Physical symptoms

Racing heart/palpitations

Excessive sweating

Feeling sick

Chest pain

Gastrointestinal discomfort or diarrhea

Feeling faint or dizzy

Trembling

Diagnostic criteria for agoraphobia:

All of the below features must be present in order to make a proper diagnosis of agoraphobia:

Marked and disproportionate fear when confronted with at least two different situations, such as open spaces, public transport or crowded areas

An immediate anxiety response such as a panic attack when exposed to the phobic stimulus

There is no single cause of agoraphobia but a number of factors have been identified as having potential links to the development of the condition:

Chemical and hormonal imbalances in the body or brain

Certain personality types, such as individuals who crave control or approval

The influence of family members as role models who may pass on traits or display excessively controlling behaviors2)

A lack of spatial awareness

Childhood trauma

An impaired fight or flight reflex

A previous history of mental illness3)

A traumatic event, such as bereavement

Agoraphobia may develop in association with places or situations in which the sufferer has previously encountered an unpleasant experience. For example, if an individual has suffered a panic attack in a specific situation, such as while shopping at the mall, they may begin to fear a repeat event and naturally try to avoid the situation in future.4)

Comorbidity

Agoraphobia may present as comorbid with other conditions, including - but not limited to:

Panic disorder

Major depression

Social phobia

Generalized anxiety disorder

Obsessive-compulsive disorder

Dysthymia

Often comorbid with panic disorder, agoraphobia can occur as the result of anxiety attacks associated with panic disorder. Sufferers will often develop a fear of the panic attacks occurring again in the same situation or place as they were previously experienced.

It is estimated that about one-third of individuals suffering from panic disorder will go on to experience agoraphobia5) as a direct result of the anxiety attacks they experience as part of their panic disorder.

Differential diagnosis

Agoraphobia is most commonly associated with panic disorder; usually, the sufferer will have a history of anxiety attacks, with symptoms of agoraphobia developing later.

However, the condition can also be diagnosed without some of the symptoms of panic - this is called agoraphobia without panic disorder. This condition differs from more general agoraphobia because the individual does not have a history of panic attacks, although the symptoms are usually similar to those of agoraphobia.

Agoraphobia without panic disorder can be triggered by various phobias, such as:

Fear of becoming a victim of crime or a terrorist attack

Concerns that being out in public could result in the contraction of a contagious disease

Worries about being humiliated or doing something embarrassing in public6)

Agoraphobia without history of panic disorder is usually treated in the same ways as agoraphobia - most commonly through therapy, medication and self-help methods, depending on the severity of the condition.

Agoraphobic avoidance behavior

People suffering from agoraphobia tend to display avoidance behavior to reduce the likelihood of having to deal with the phobic stimulus. Typical situations avoided by agoraphobia sufferers include:

Driving

Being alone outside the home

Shopping at busy places like the mall

Using public transport

If the individual has to face the phobic stimulus, they will often take precautions such as sticking to a predefined set route, which they feel is the safest way of navigating the situation. Another common behavior among sufferers of agoraphobia is to keep medication or cellphones on their person if a phobic situation will be encountered7).

Diverting from the ‘safe route’ or facing the phobic stimulus without the safety precautions perceived necessary can cause agoraphobia sufferers to experience extreme anxiety and discomfort.

Living with agoraphobia

Agoraphobia affects around 1.8 million adults in the USA alone, according to statistics8). Sufferers can experience the disorder at varying levels of severity and for different lengths of time.

Life with agoraphobia varies from person to person; some sufferers may avoid specific situations that evoke panic - others experience more extreme lifestyle effects and become completely housebound. Many people suffering from agoraphobia assign themselves a ‘safe area’ in which they are happy to travel; outside of this area, agoraphobics may struggle with anxiety and require the help and support of friends or relatives.

Early diagnosis is sometimes difficult to obtain as agoraphobia may be misdiagnosed or comorbid with other disorders; however, once diagnosed, agoraphobia can be treated in a number of ways. The success of treatment depends on the individual and the severity of their condition.

Treatment

There are various forms of treatment for agoraphobia, namely:

Self-help techniques - learning more about agoraphobia and related conditions like panic disorder and panic attacks can be helpful in developing awareness and adopting self-help techniques like deep breathing and visualization

Stress management - taking regular exercise, cutting out caffeine and nicotine and applying principles of mindfulness and relaxation can help reduce stress and alleviate symptoms of agoraphobia

Cognitive behavioral therapy (CBT) - utilized as a means of breaking a negative cycle of thinking and behavior, CBT conditions patients to adopt more positive ways of thinking, combined with exposure therapy to challenge fears

Medication - various types of medication are used to treat agoraphobia, including selective serotonin reuptake inhibitors to improve mood and feelings of anxiety, beta-blockers like propranolol to stabilize the heartbeat and anti-anxiety drugs called benzodiazepines

In many cases, agoraphobia is treated with a combination of medication and therapy - most commonly CBT, which can be delivered on an individual level or via group therapy. Patients will often be set tasks to complete outside their sessions to enhance desensitization to the phobic stimulus and overcome their phobia at a manageable level9).

Agoraphobia may be temporary or lifelong, but can be managed with treatment to gradually improve the sufferer’s quality of life.

Dr. Kevin Fleming obtained his PhD from Notre Dame and is the Founder of Grey Matters International (www.greymattersintl.com) a neuroscience-based behavior change consulting firm.

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